Subclavian and axillary vessel anatomy: a prospective observational ultrasound study.

PURPOSE: The primary objective of this study was to define the ultrasound-derived anatomy of the axillary/subclavian vessels. As a secondary objective, we evaluated the relationship between the vascular anatomy and demographic, anthropometric, and hemodynamic data of patients. METHODS: This observational anatomical study used bedside ultrasound with 150 cardiac surgical patients in the operating room. Bilateral axillary and subclavian anatomy was determined using a high-frequency ultrasound probe with fixed reference points. Images were recorded and analyzed, and correlation with demographic, anthropometric, and hemodynamic data was performed. RESULTS: The images were adequate to evaluate potential anatomical variations in 97.4% of patients with a body mass index as high as 46.4 kg·m-2. The mean (standard deviation) diameter of the axillary vein was 1.2 (0.3) cm on the right side and 1.1 (0.2) cm on the left side. The dimensions of the axillary vein were larger on the right side in 69% of patients. The vein was located directly over the artery in the mid-clavicular view in 67% of the patients and in lateral-clavicular view in only 7% of the patients. As we moved the probe laterally, the vein was lateralized in relation to the artery in 89% of patients. There was no significant correlation between the hemodynamic data and vessel size, although direct correlation was found between body mass index and the depth of the vessel (P < 0.001). The axillary vein area was smaller in females than in males (P < 0.002), and in 4% of patients, the axillary vein was in an aberrant position. CONCLUSIONS: In patients undergoing cardiac surgery, axillary vessel anatomy varied considerably, and the patients' hemodynamics could not predict the size of the axillary vessels. Only the patients' weight correlated moderately with the depth of the vein.

Embryological and comparative description of the cephalic vein joining the external jugular vein: A case report.

The cephalic vein arises from the radial end of the dorsal venous arch. It turns around the radial border of the forearm and passes proximally along the arm to the shoulder, where it enters the axillary vein by penetrating the clavipectoral triangle. The cephalic vein is prone to vary at the antecubital fossa, where it forms numerous anastomoses. A male cadaver fixated with a 10% formalin solution was dissected during regular anatomy lessons. It was found that the cephalic vein crossed the upper third of the arm between two fasciculi of the deltoid muscle and reached the shoulder, where it passed above the acromion and crossed the posterior border of the clavicle in order to join the external jugular vein. The cephalic vein is one of the most used veins for innumerous activities, such as venipunctures and arteriovenous fistula creation. Furthermore, it is an anatomical landmark known for its consistent anatomy, as it possesses low rates of variability. Despite that, its anatomical variations are clinically and surgically significant and healthcare professionals must be aware of the variations of this vessel. We aim to report a rarely described variation of the cephalic vein and discuss its embryological, phylogenetic and clinical features.

No effect of Valsalva maneuver or Trendelenburg angle on axillary vein size.

BACKGROUND: A new technique for establishing ultrasound-guided central access involves the use of the axillary vein, the distal projection of the subclavian vein, via the lateral chest. OBJECTIVE: To examine the effects of Valsalva maneuver and Trendelenburg positioning on axillary vein cross-sectional area (CSA). METHODS: Using a group-sequential design, we enrolled stable emergency patients and measured their axillary veins sonographically. Patients were measured while supine, then after a Valsalva maneuver, and then at 5°, 10°, 15°, and 17° of Trendelenburg positioning, pausing 2 min after each change. We asked patients to score their discomfort from 0 to 10 in each position. RESULTS: We enrolled 30 adult patients with a median age of 39 years (range, 20-66 years). Treating physicians considered 11 of these patients to have hypovolemia. The Valsalva maneuver decreased CSA (Mean difference = -0.03 cm(2)), (95% confidence interval [CI] -0.10-0.04). Trendelenburg positioning did not statistically increase CSA. The 5° position caused the largest increase, that is, 0.04 cm(2) (95% CI -0.04-0.12) in the entire group and 0.1 cm(2) (95% CI -0.07-0.28) in the hypovolemic subgroup. At greater degrees of Trendelenburg positioning, patients reported higher discomfort scores or simply dropped out. CONCLUSION: The Valsalva maneuver and Trendelenburg angles above 10° do not increase axillary vein area but do increase patient discomfort. Our data suggest optimal positioning in the supine resting position or at a 5° Trendelenburg position.

Fenestration of axillary vein by a variant axillary artery.

Variations of venous pattern in the arm are common. In this case report, we present a variation of axillary artery and vein. During routine educational dissections of axillary region, it was observed that a fenestrated axillary vein was perforated by a variant axillary artery in right arm of an old male cadaver. The axillary artery which was fenestrated through axillary vein had only two branches arising from its second part and no branches from its remaining distal parts. The branches are thoraco-acromial (usual) and another large collateral (unusual) branch. This collateral branch is the origin of several important arteries as the subscapular, circumflex scapular, posterior circumflex humeral and lateral thoracic arteries. We propose to name this artery as collateral axillary arterial trunk. The course of this collateral axillary arterial trunk and its branches and also clinical significance of this variation are discussed in the paper.

In vivo study of the surgical anatomy of the axilla.

BACKGROUND: Classical anatomical descriptions fail to describe variants often observed in the axilla as they are based on studies that looked at individual structures in isolation or textbooks of cadaveric dissections. The presence of variant anatomy heightens the risk of iatrogenic injury. The aim of this study was to document the nature and frequency of these anatomical variations based on in vivo peroperative surgical observations. METHODS: Detailed anatomical relationships were documented prospectively during consecutive axillary dissections. Relationships between the thoracodorsal pedicle, course of the lateral thoracic vein, presence of latissimus dorsi muscle slips, variations in axillary and angular vein anatomy, and origins and branching of the intercostobrachial nerve were recorded. RESULTS: Among a total of 73 axillary dissections, 43 (59 per cent) revealed at least one anatomical variant. Most notable variants included aberrant courses of the thoracodorsal nerve in ten patients (14 per cent)--three variants; lateral thoracic vein in 12 patients (16 per cent)--four variants; bifid axillary veins in ten patients (14 per cent); latissimus dorsi muscle slips in four patients (5 per cent); and variants in intercostobrachial nerve origins and branching in 26 patients (36 per cent). The angular vein, a subscapular vein tributary, was found to be a constant axillary structure. CONCLUSION: Variations in axillary anatomical structures are common. Poor understanding of these variants can affect the adequacy of oncological clearance, lead to vascular injury, compromise planned microvascular procedures and result in chronic pain or numbness from nerve injury. Surgeons should be aware of the common anatomical variants to facilitate efficient and safe axillary surgery.

Novel findings of the anatomy and variations of the axillary vein and its tributaries.

The anatomy and variations of the axillary vein has significant implications in various invasive procedures such as venous access, axillary block, arteriovenous fistula creation, axillary node dissection, breast augmentation, and other surgical procedures involving the axilla. To clarify the anatomy of the axillary vein and its tributaries, 40 cadaveric upper extremities were examined after dissection and were classified into several types according to the courses and terminations of brachial veins. The brachial veins ended separately (Type A; 72.5%) or made a common brachial vein (Type B; 27.5%) to enter the basilic vein or the axillary vein. The basilic vein was absent in 5.0% of the specimens. Duplication of the axillary vein was observed in 17.5% of the specimens and the lateral venous channel running along the lateral wall of the axilla was observed in 40.0% of the specimens. The most common drainage vein of the deep brachial vein was the lateral brachial vein (67.5%). The anterior circumflex humeral vein also emptied into the lateral brachial vein in 67.5% of the specimens. The posterior circumflex humeral vein crossed posterior side of the brachial plexus to join either the axillary vein (45.0%) or subscapular vein (42.5%). Perforation of the lateral root of median nerve by a lateral brachial vein, a common brachial vein, or a venous channel was observed in 15.0% of the specimens. Other venous variations accompanying the variations of the axillary artery or the brachial artery are described herein. The clinical importance of these findings is described in the discussion.

[Pediatric central venous catheterization through the axillary veins using ultrasound guidance].

BACKGROUND: Axillary veins (AXVs) are selected for the central venous catheterization (CVC) in adults using ultrasound echo but quite rarely in children. We evaluated the relationships between the widths and the depths of the pediatric AXVs. METHODS: The widths and the depths of the AXVs were measured using an ultrasound echo apparatus in fifty patients. RESULTS: The widths and depths of the AXVs were about 3.8 and 10.0 mm in patients of about 75.7 cm in height. In 35 children less than 80 cm in height, AXVs depth to width ratios (D/W) averaged 3.6, and the CVC through the AXVs seemed difficult, whereas in 7 children of more than 100 cm in height, D/W averaged 1.7, and it seemed easy. CONCLUSIONS: We should know the AXV characteristics to secure the pediatric CVC through the AXV.

Position of valves within the subclavian and axillary veins.

BACKGROUND: The aim of this explorative morphologic study was to determine the position and frequency of the valves in the axillary and subclavian veins. METHODS: The position and frequency of the valves in the subclavian and axillary veins were studied macroscopically in 59 limbs from 30 cadavers. We measured in situ with a measuring tape, starting from the venous angle toward the initiation of the axillary vein. All cadavers were bequeathed by informed consent. RESULTS: A terminal valve existed in all subclavian veins within the range of 0.0 to 27.5 mm (mean: left, 13.87 mm; right, 9.78 mm) distally to the venous angle; a second valve existed in one left and one right subclavian vein at a distance of 30.0 and 30.5 mm, respectively. All left axillary veins had a "most proximal" valve (mean, 103.4 mm), 73.3% also possessed a second valve (mean, 140.48 mm), and 16.7% had a third valve (mean, 153.9 mm). All right axillary veins possessed at least one valve (mean, 100.07 mm), 75.86% had a second valve (mean, 134.55 mm), 34.48% also had a third valve (mean, 157.30 mm), and 10.3% had a fourth valve (mean, 140.0 mm). CONCLUSIONS: All of the axillary and subclavian veins in our specimens possessed at least one valve. All the valves in the subclavian veins were concentrated to the proximal half, resulting in a valveless distal half. The subclavian vein rarely had a second valve. The valves in the axillary veins were located in the distal half, resulting in a valveless proximal half. The axillary vein can have one to four valves. No relation was evident between the frequency of the valves and the age of the donors when they died. Many other factors may influence the frequency of the valves in the axillary vein.

Impact of sex, age and BMI on depth and diameter of the infraclavicular axillary vein when measured by ultrasonography.

BACKGROUND AND OBJECTIVE: The axillary vein is another option for central venous catheterisation, with less chance of accidental arterial puncture as there is a greater distance between artery and vein, and from vein to rib cage, compared with other sites. Better success, lower complication rates and faster access can be achieved with ultrasound guidance which is becoming the established technique for central venous catheterisation. We measured two key factors for successful infraclavicular axillary venous catheterisation: depth and diameter of the infraclavicular axillary vein in its medial part using ultrasound. METHODS: We recruited 98 patients, classified according to sex, age and BMI. Groups were divided according to BMI as follows: group 1 (≤20 kg m⁻²), group 2 (20.01-25.00 kg m⁻²) and group 3 (>25 kg m⁻²); and these were further subdivided according to age: 20-39 years, 40-59 years and 60-80 years. The depth and diameter of the infraclavicular axillary vein was measured at a point between the medial third and midpoint of the clavicle. RESULTS: Vein diameter was significantly different between men and women (P = 0.005), whereas depth showed no significant difference. In the BMI subgroups, there was a significant difference in depth (P < 0.001), and a trend to significant difference in diameter (P = 0.056). However, age-specific differences in depth and diameter were not observed. CONCLUSION: During catheterisation of infraclavicular axillary vein, real-time visualisation of the needle tip when using ultrasound to gauge vein depth and diameter may diminish major complications such as pneumothorax and artery puncture.

[On the characteristics of axillary veins and internal jugular veins in pediatric patients].

BACKGROUND: Axillary veins (AxV) are increasingly selected instead of the subclavian veins (SCV) for safe and successful catheterization in adults using ultrasound echo although quite rarely in children. The diameters and depths of the pediatric internal jugular veins (IJV) are well known but those of pediatric AxV are unfamiliar even to anesthesiologists. We evaluated the diameters and the depths of the AxV and IJV in children undergoing cardiac surgery. METHODS: The diameters and the depths of the AxV and IJV were measured using an ultrasound echo apparatus (TiTAN, SonoSite) in fifty pediatric patients. RESULTS: The patients' ages, heights, and weights averaged about 27.5 months, 77.3cm, and 9.8kg, respectively. The maximal widths, lengths and depths of the AxV and IJV were about 4.2, 3.3 and 10 mm and 7.5, 4.9 and 6.6 mm, respectively. The widths of the AxV and IJV correlated well with the patients' heights (r=0.831 and 0.700, respectively). CONCLUSIONS: The diameters of the AxV are about 0.6 times and the depths are about 1.5 times those of the IJV and it seems difficult to use AxV for pediatric CVC from the standpoint of venous diameters and depths.

Diagnosis and management of Paget-Schroetter's syndrome.

Paget-Schroetter's syndrome (PSS) is an effort-related syndrome involving upper extremity deep vein thromboses (UEDVTs) that usually occur in the subclavian or axillary veins. The aetiology is distinct from that of lower extremity DVTs (LEDVTs). Although rare, the syndrome can occur in young, otherwise healthy people who participate in upper extremity activity (Roche-Nagle et al 2007) such as footballer Gary Cahill, a defender at Bolton Wanderers, whose hopes of playing football at international level this season have diminished as a result of developing a UEDVT (BBC Sport 2010). This article discusses the incidence and aetiology, and provides a case study, of the syndrome.

The axillary vein and its tributaries are not in the mirror image of the axillary artery and its branches.

INTRODUCTION: The axillary and cephalic veins are used for various clinical purposes but their anatomy is not fully understood. Increased knowledge and information about them as well as superficial veins in the upper arm would be useful. OBJECTIVE: The aim of this study is to contribute to the literature regarding the anatomy of the venous drainage of the upper extremity. METHODS: The veins of forty upper extremities from twenty one adult cadavers were injected and their axillary regions dissected. The course and pattern of drainage of the venous tributaries in the axillary region were identified and recorded. RESULTS: The basilic, brachial, subscapular, lateral thoracic and superior thoracic veins drained mainly into the axillary vein, in common with most textbook descriptions. However, the thoracoacromial veins were observed to drain into the cephalic vein in 70.0% of upper limbs. In addition, a venous channel connecting the distal part and proximal part of the axilla was found along the posterolateral wall of the axilla in 77.5% of the upper limbs. In 95.0% of upper limbs, we discovered a superficial vein which ran from the axillary base and drained directly into the axillary vein. CONCLUSION: The veins from the inferomedial part of the axilla drain into the axillary vein, whereas the veins from the superolateral part of the axilla drain into the cephalic vein. The venous drainage of the axilla is variable and in common with venous drainage elsewhere, does not necessarily follow the pattern of the arterial supply.

The clinical anatomy of the cephalic vein in the deltopectoral triangle.

Identification and recognition of the cephalic vein in the deltopectoral triangle is of critical importance when considering emergency catheterization procedures. The aim of our study was to conduct a cadaveric study to access data regarding the topography and the distribution patterns of the cephalic vein as it relates to the deltopectoral triangle. One hundred formalin fixed cadavers were examined. The cephalic vein was found in 95% (190 right and left) specimens, while in the remaining 5% (10) the cephalic vein was absent. In 80% (152) of cases the cephalic vein was found emerging superficially in the lateral portion of the deltopectoral triangle. In 30% (52) of these 152 cases the cephalic vein received one tributary within the deltopectoral triangle, while in 70% (100) of the specimens it received two. In the remaining 20% (38) of cases the cephalic vein was located deep to the deltopectoral fascia and fat and did not emerge through the deltopectoral triangle but was identified medially to the coracobrachialis and inferior to the medial border of the deltoid. In addition, in 4 (0.2%) of the specimens the cephalic vein, after crossing the deltopectoral triangle, ascended anterior and superior to the clavicle to drain into the subclavian vein. In these specimens a collateral branch was observed to communicate between the cephalic and external jugular veins. In 65.2% (124) of the cases the cephalic vein traveled with the deltoid branch of the thoracoacromial trunk. The length of the cephalic vein within the deltopectoral triangle ranged from 3.5 cm to 8.2 cm with a mean of 4.8+/-0.7 cm. The morphometric analysis revealed a mean cephalic vein diameter of 0.8+/-0.1 cm with a range of 0.1 cm to 1.2 cm. The cephalic vein is relatively large and constant, usually allowing for easy cannulation.

Generalized changes in venous distensibility in postthrombotic patients.

INTRODUCTION: In situ biomechanical properties of peripheral large veins were compared between asymptomatic young patients who had previously unilateral femoro-popliteal deep venous thrombosis (DVT) and age-matched, healthy controls; the aim of this study was to assess local or generalized alterations of venous wall biomechanics in postthrombotic patients. PATIENTS AND METHODS: Inner diameters of both common femoral veins, right axillary vein, and right internal jugular veins were measured in two directions by ultrasonography. Venous pressure was altered by posture changes (standing and lying) and by application of graded and controlled Valsalva. Ten postthrombotic young patients without any symptoms and 11 age-matched control subjects were included. RESULTS: In postthrombotic patients, both the affected and unaffected common femoral vein diameters and capacities were larger at low transmural pressures than those for the control group, but they demonstrated significantly less distensibility when higher pressures were applied. Similarly, in the internal jugular vein, capacity without Valsalva was significantly higher in postthrombotic patients and distensibility was reduced (statistically significant in the erect position). Pressure-induced changes in axillary vein diameter were negligible. CONCLUSIONS: In situ diameter and capacity changes, and in situ distensibility of the femoral veins on both sides (i.e., the side of previous thrombosis as well as the disease-free side) and of the jugular veins are reduced in the young DVT patients compared to veins of the age-matched, healthy controls. The pathophysiological mechanism of generalized venous wall changes in these young DVT patients remains unknown.

The axillary arch: anatomy and suggested clinical manifestations.

The purpose of this commentary is to describe bilateral anomalous bands of the latissimus dorsi muscle observed in an 81-year-old male embalmed cadaver, and to discuss the possible clinical implications of this anomaly. The musculotendinous bands tautened and compressed the underlying axillary vessels, and the musculocutaneous, median, and ulnar nerves during passive abduction/external rotation of the shoulder. Similar variations found in the latissimus dorsi muscles in this commentary have been reported in the anatomical and surgical literature. These reports include descriptions of the anomalous bands of the latissimus dorsi attaching to the coracoid process, pectoralis major muscle, and fascia of the coracobrachialis muscle. The potential presence of an axillary arch presents several clinical considerations for the physical therapist. The existence of an axillary arch should be considered in patients with signs and symptoms consistent with upper extremity neurovascular compromise similar to thoracic outlet syndrome. Including this variant in the differential diagnostic process may assist physical therapists in the management of patients with signs and symptoms consistent with thoracic outlet syndrome.

Locating the axillary vein and preserving the medial pectoral nerve.

The exposure for an axillary dissection has become more limited as surgical treatment for breast cancer has evolved from a radical mastectomy to a limited axillary dissection. Exposure of the axillary vein is made more difficult by the smaller incisions, by preservation of intercostobrachial nerves, and by the induration resulting from a previous sentinel node biopsy. To assist in the identification of the axillary vein, I describe the course of a visible but small vein adjacent to the medial pectoral nerve. The vein can be easily identified at the lateral edge of the pectoralis major. It, frequently together with the medial pectoral nerve, traverses in a craniomedial direction and leads to either the lateral thoracic vein (near its junction with the axillary vein) or directly to the axillary vein. Dissection of this vessel identifies the axillary vein, preserves the medial pectoral nerve and allows a more complete and safe level II dissection.

The low anterior five-o'clock portal during arthroscopic shoulder surgery performed in the beach-chair position.

We evaluated the difficulty, accuracy, and safety of establishing a low anterior 5-o'clock portal for anterior capsulolabral repair in patients positioned in the beach-chair position during shoulder arthroscopy. An initial 5-o'clock portal was created using an inside-out technique as described by Davidson and Tibone. During establishment of the portal, significant force was required to lever the humeral head laterally, and chondral indentations were noted in several specimens. Because of the difficulty noted establishing the 5-o'clock portal using an inside-out technique, we attempted to establish a 5-o'clock anterior portal using an outside-in technique. Seven fresh-frozen cadaveric shoulders underwent shoulder arthroscopy in the beach-chair position. After the establishment of a 3-o'clock portal, a specially constructed guide was used to place a pin at the 5-o'clock position. The distances of the pins from the cephalic vein and the musculocutaneous and axillary nerves were recorded. The bottom (5-o'clock position) and top (3-o'clock position) pins varied from 12 to 20 mm from the musculocutaneous and axillary nerves. The bottom pin was located within 2 mm of the cephalic vein and varied from medial to lateral in different specimens. We do not recommend the use of a 5-o'clock portal using an inside-out or outside-in technique for patients positioned in the beach-chair position during shoulder arthroscopy because of the potential for cephalic vein or articular cartilage injury.

The axillary vein central venous catheter in severely burned patients.

In severely burned patients the approach to the central vein is often difficult due to concomitant edema, but also due to the fact that the skin area, where commonly used approaches are performed, is burned as well, whereas the axillary region is often not involved. In order to perform an axillary approach to the central vein as an alternative to the commonly used approaches in patients, an anatomical dissection in fresh human cadavers was carried out. Considering the anatomical landmarks which were found during dissection of the axillary region, the axillary approach to the central vein was used in 35 patients in our intensive burn care unit with unaffected axillary skin. In three cases the only complication observed was an occasional puncture of the axillary artery without major hematoma. The infection rate of the catheters was similar to the commonly used puncture sites. This approach to the central venous line in severely burned patients can be recommended.

Morphometric examination of the free scapular flap.

In this study we investigated the clinicoanatomic basis of the scapular flap by morphometric examinations of 42 cadavers. Our findings were as follows: With common-trunk type scapular vessels, the maximal lengths of arteries and veins that could be used for a flap pedicle were 93 and 91 mm. With direct-type scapular vessels, the maximal lengths were 95 and 71 mm. In common-trunk type vessels, the mean internal diameter 2 mm distal from the confluence of the scapular vessel was 2.8 mm for arteries and 3.3 mm for veins. In the direct-type vessels, the mean internal diameter 2 mm distal from the confluence of the circumflex scapular vessel was 1.8 mm for arteries and 3.3 mm for veins. The maximal superoinferior dimension of the scapular graft was 28 mm. The maximal lateral dimension of the scapular graft was 12 mm.